White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Disposable Exhalation Port

Facility

$154.36

Hospital Charge Code	993633
Hospital Revenue Code	270
Rate for Payer: Cash Price	$104.96

DISPOSABLE FLUTED HEADLESS PINS

Facility

$2,047.54

Service Code	HCPCS C1713
Hospital Charge Code	993505
Hospital Revenue Code	278
Min. Negotiated Rate	$511.88
Max. Negotiated Rate	$1,023.77
Rate for Payer: Cash Price	$1,392.33
Rate for Payer: Cigna Commercial	$511.88
Rate for Payer: Multiplan Auto	$1,023.77
Rate for Payer: Multiplan Commercial	$1,023.77
Rate for Payer: Multiplan Workers Comp	$1,023.77
Rate for Payer: Scott and White EPO/PPO	$1,023.77

DISPOSABLE FLUTED HEADLESS PINS

Facility

$2,047.54

Service Code	HCPCS C1713
Hospital Charge Code	993505
Hospital Revenue Code	278
Min. Negotiated Rate	$184.28
Max. Negotiated Rate	$1,474.23
Rate for Payer: Amerigroup CHIP/Medicaid	$184.28
Rate for Payer: BCBS of TX Blue Advantage	$614.26
Rate for Payer: BCBS of TX Blue Essentials	$737.11
Rate for Payer: BCBS of TX PPO	$819.02
Rate for Payer: Cash Price	$1,392.33
Rate for Payer: Cigna Medicaid	$1,474.23
Rate for Payer: Molina CHIP/Medicaid	$1,474.23
Rate for Payer: Multiplan Auto	$1,023.77
Rate for Payer: Multiplan Commercial	$1,023.77
Rate for Payer: Multiplan Workers Comp	$1,023.77
Rate for Payer: Parkland Medicaid	$1,474.23
Rate for Payer: Scott and White EPO/PPO	$1,023.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,474.23
Rate for Payer: Superior Health Plan EPO	$278.47

Disposable Infu-Surg Pressure Infusion Bag with Hook, 500 mL

Facility

$317.98

Hospital Charge Code	992912
Hospital Revenue Code	270
Min. Negotiated Rate	$28.62
Max. Negotiated Rate	$228.95
Rate for Payer: Amerigroup CHIP/Medicaid	$28.62
Rate for Payer: BCBS of TX Blue Advantage	$95.39
Rate for Payer: BCBS of TX Blue Essentials	$114.47
Rate for Payer: BCBS of TX PPO	$127.19
Rate for Payer: Cash Price	$216.23
Rate for Payer: Cigna Medicaid	$228.95
Rate for Payer: Molina CHIP/Medicaid	$228.95
Rate for Payer: Multiplan Auto	$206.69
Rate for Payer: Multiplan Commercial	$206.69
Rate for Payer: Multiplan Workers Comp	$206.69
Rate for Payer: Parkland Medicaid	$228.95
Rate for Payer: Scott and White EPO/PPO	$158.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$228.95
Rate for Payer: Superior Health Plan EPO	$43.25

Disposable Infu-Surg Pressure Infusion Bag with Hook, 500 mL

Facility

$317.98

Hospital Charge Code	992912
Hospital Revenue Code	270
Rate for Payer: Cash Price	$216.23

Disposable light handle cover, blue sterile

Facility

$6.27

Hospital Charge Code	992788
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.26

Disposable light handle cover, blue sterile

Facility

$6.27

Hospital Charge Code	992788
Hospital Revenue Code	272
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$4.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.56
Rate for Payer: BCBS of TX Blue Advantage	$1.88
Rate for Payer: BCBS of TX Blue Essentials	$2.26
Rate for Payer: BCBS of TX PPO	$2.51
Rate for Payer: Cash Price	$4.26
Rate for Payer: Cigna Medicaid	$4.51
Rate for Payer: Molina CHIP/Medicaid	$4.51
Rate for Payer: Multiplan Auto	$4.08
Rate for Payer: Multiplan Commercial	$4.08
Rate for Payer: Multiplan Workers Comp	$4.08
Rate for Payer: Parkland Medicaid	$4.51
Rate for Payer: Scott and White EPO/PPO	$3.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.51
Rate for Payer: Superior Health Plan EPO	$0.85

DISPOSABLE MIXING BOWLS W/S PATULA

Facility

$58.31

Hospital Charge Code	992723
Hospital Revenue Code	272
Rate for Payer: Cash Price	$39.65

DISPOSABLE MIXING BOWLS W/S PATULA

Facility

$58.31

Hospital Charge Code	992723
Hospital Revenue Code	272
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$41.98
Rate for Payer: Amerigroup CHIP/Medicaid	$5.25
Rate for Payer: BCBS of TX Blue Advantage	$17.49
Rate for Payer: BCBS of TX Blue Essentials	$20.99
Rate for Payer: BCBS of TX PPO	$23.32
Rate for Payer: Cash Price	$39.65
Rate for Payer: Cigna Medicaid	$41.98
Rate for Payer: Molina CHIP/Medicaid	$41.98
Rate for Payer: Multiplan Auto	$37.90
Rate for Payer: Multiplan Commercial	$37.90
Rate for Payer: Multiplan Workers Comp	$37.90
Rate for Payer: Parkland Medicaid	$41.98
Rate for Payer: Scott and White EPO/PPO	$29.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.98
Rate for Payer: Superior Health Plan EPO	$7.93

disposable or towel

Facility

$5.36

Hospital Charge Code	993755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.64

disposable or towel

Facility

$5.36

Hospital Charge Code	993755
Hospital Revenue Code	270
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$3.86
Rate for Payer: Amerigroup CHIP/Medicaid	$0.48
Rate for Payer: BCBS of TX Blue Advantage	$1.61
Rate for Payer: BCBS of TX Blue Essentials	$1.93
Rate for Payer: BCBS of TX PPO	$2.14
Rate for Payer: Cash Price	$3.64
Rate for Payer: Cigna Medicaid	$3.86
Rate for Payer: Molina CHIP/Medicaid	$3.86
Rate for Payer: Multiplan Auto	$3.48
Rate for Payer: Multiplan Commercial	$3.48
Rate for Payer: Multiplan Workers Comp	$3.48
Rate for Payer: Parkland Medicaid	$3.86
Rate for Payer: Scott and White EPO/PPO	$2.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.86
Rate for Payer: Superior Health Plan EPO	$0.73

DISPOSABLES KIT FOR DX KNOTLESS FIBERTAX

Facility

$2,083.86

Hospital Charge Code	992599
Hospital Revenue Code	272
Min. Negotiated Rate	$187.55
Max. Negotiated Rate	$1,500.38
Rate for Payer: Amerigroup CHIP/Medicaid	$187.55
Rate for Payer: BCBS of TX Blue Advantage	$625.16
Rate for Payer: BCBS of TX Blue Essentials	$750.19
Rate for Payer: BCBS of TX PPO	$833.54
Rate for Payer: Cash Price	$1,417.02
Rate for Payer: Cigna Medicaid	$1,500.38
Rate for Payer: Molina CHIP/Medicaid	$1,500.38
Rate for Payer: Multiplan Auto	$1,354.51
Rate for Payer: Multiplan Commercial	$1,354.51
Rate for Payer: Multiplan Workers Comp	$1,354.51
Rate for Payer: Parkland Medicaid	$1,500.38
Rate for Payer: Scott and White EPO/PPO	$1,041.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,500.38
Rate for Payer: Superior Health Plan EPO	$283.40

DISPOSABLES KIT FOR DX KNOTLESS FIBERTAX

Facility

$2,083.86

Hospital Charge Code	992599
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,417.02

Distilled Water, Laboratory Reagent Grade, 5-gal

Facility

$539.03

Hospital Charge Code	993339
Hospital Revenue Code	270
Min. Negotiated Rate	$48.51
Max. Negotiated Rate	$388.10
Rate for Payer: Amerigroup CHIP/Medicaid	$48.51
Rate for Payer: BCBS of TX Blue Advantage	$161.71
Rate for Payer: BCBS of TX Blue Essentials	$194.05
Rate for Payer: BCBS of TX PPO	$215.61
Rate for Payer: Cash Price	$366.54
Rate for Payer: Cigna Medicaid	$388.10
Rate for Payer: Molina CHIP/Medicaid	$388.10
Rate for Payer: Multiplan Auto	$350.37
Rate for Payer: Multiplan Commercial	$350.37
Rate for Payer: Multiplan Workers Comp	$350.37
Rate for Payer: Parkland Medicaid	$388.10
Rate for Payer: Scott and White EPO/PPO	$269.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$388.10
Rate for Payer: Superior Health Plan EPO	$73.31

Distilled Water, Laboratory Reagent Grade, 5-gal

Facility

$539.03

Hospital Charge Code	993339
Hospital Revenue Code	270
Rate for Payer: Cash Price	$366.54

DISTRACTOR LINEAR TELESCOPIC

Facility

$2,275.31

Hospital Charge Code	138444
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,547.21

DISTRACTOR LINEAR TELESCOPIC

Facility

$2,275.31

Hospital Charge Code	138444
Hospital Revenue Code	272
Min. Negotiated Rate	$204.78
Max. Negotiated Rate	$1,638.22
Rate for Payer: Amerigroup CHIP/Medicaid	$204.78
Rate for Payer: BCBS of TX Blue Advantage	$682.59
Rate for Payer: BCBS of TX Blue Essentials	$819.11
Rate for Payer: BCBS of TX PPO	$910.12
Rate for Payer: Cash Price	$1,547.21
Rate for Payer: Cigna Medicaid	$1,638.22
Rate for Payer: Molina CHIP/Medicaid	$1,638.22
Rate for Payer: Multiplan Auto	$1,478.95
Rate for Payer: Multiplan Commercial	$1,478.95
Rate for Payer: Multiplan Workers Comp	$1,478.95
Rate for Payer: Parkland Medicaid	$1,638.22
Rate for Payer: Scott and White EPO/PPO	$1,137.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,638.22
Rate for Payer: Superior Health Plan EPO	$309.44

DISTRACTOR SUPINE UC HIP

Facility

$1,362.00

Hospital Charge Code	145901
Hospital Revenue Code	272
Rate for Payer: Cash Price	$926.16

DISTRACTOR SUPINE UC HIP

Facility

$1,362.00

Hospital Charge Code	145901
Hospital Revenue Code	272
Min. Negotiated Rate	$122.58
Max. Negotiated Rate	$980.64
Rate for Payer: Amerigroup CHIP/Medicaid	$122.58
Rate for Payer: BCBS of TX Blue Advantage	$408.60
Rate for Payer: BCBS of TX Blue Essentials	$490.32
Rate for Payer: BCBS of TX PPO	$544.80
Rate for Payer: Cash Price	$926.16
Rate for Payer: Cigna Medicaid	$980.64
Rate for Payer: Molina CHIP/Medicaid	$980.64
Rate for Payer: Multiplan Auto	$885.30
Rate for Payer: Multiplan Commercial	$885.30
Rate for Payer: Multiplan Workers Comp	$885.30
Rate for Payer: Parkland Medicaid	$980.64
Rate for Payer: Scott and White EPO/PPO	$681.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$980.64
Rate for Payer: Superior Health Plan EPO	$185.23

divalproex sodium 250 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77520916
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

divalproex sodium 250 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77520916
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

divalproex sodium 500 mg DR Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77521024
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

divalproex sodium 500 mg DR Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77521024
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Diverticulectomy of hypopharynx or esophagus, with or without myotomy cervical approach

Facility

$6,956.78

Service Code	HCPCS 43130
Hospital Charge Code	9900666
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,730.61

Diverticulectomy of hypopharynx or esophagus, with or without myotomy cervical approach

Facility

$12,570.48

Service Code	CPT 43130
Hospital Charge Code	36043130
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$11,001.60
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Know your out-of-pocket cost for care.

All Charges